Healthcare Provider Details

I. General information

NPI: 1447706502
Provider Name (Legal Business Name): JENIELLE DAUGHERTY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 BRIARGATE PARKWAY SUITE #300
COLORADO SPRINGS CO
80920
US

IV. Provider business mailing address

4100 BRIARGATE PARKWAY SUITE #300
COLORADO SPRINGS CO
80920
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-7669
  • Fax:
Mailing address:
  • Phone: 719-632-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number0992438
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: